Monday, July 29, 2013
Two Studies Should Lead to Radical Change in Mental Illness Treatment
Thursday, August 30, 2012
Libertarians should support involuntary commitment reform.
A LIBERTARIAN’S PROPOSAL TO REFORM INVOLUNTARY COMMITMENT
The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness—free them from the Bastille of their psychoses—and restore their dignity, their free will and the meaningful exercise of their liberties.[1]
But as a result of our current restrictive commitment procedures, persons with mental illness kill 1,000 individuals annually, roughly 10% of all homicides.[4] The most likely victims are family members,[5] police, and sheriffs.[6] Take the parents of mentally ill Eric Bellucci in Staten Island. They were so fearful of their son, who had been hospitalized and involuntarily committed multiple times, that they locked him out of the house. So he camped in their yard. They begged to have him civilly committed, but the law required Eric to first become "dangerous." So he did. On October 13, 2010 he stabbed both his parents. They are dead and Eric will be permanently incarcerated. Hardly a victory for individual liberties.
Untreated schizophrenia and untreated bipolar disorder are two of the disorders most likely to be represented among civilly committed populations. I’ll limit this discussion to schizophrenia.
John Stuart Mill's introduction to On Liberty stated, “It is, perhaps, hardly necessary to say that this doctrine is meant to apply only to human beings in the “maturity of their faculties.” He was wrong. Some libertarians need reminding.
Nowhere is the debate over civil commitment less informed than when it comes to answering the question “Are people with mental illness more violent than others?”[24] It is largely irrelevant, because civil commitment is not aimed at the 25-40% of Americans some claim have a "diagnosable mental disorder"—your friends on Prozac.
By reducing hallucinations and delusions, and by restoring “maturity of faculties,” medication reduces violence. This should be readily apparent because almost everyone civilly committed because they were dangerous is eventually released—because they are no longer dangerous. The difference between their pre-commitment state and post-commitment state was the administration of medicines.
Individuals with mental illness are allowed to refuse treatment and cannot be treated in the community system unless they volunteer. For the most seriously ill, this is often an insurmountable hurdle because of their anosognosia, neurocognitive dysfunction, hallucinations, and delusions. Individuals who need the community mental health system the most cannot get in.[27] They are allowed to deteriorate to dangerousness and then become subject to the involuntary commitment system.
From a libertarian’s perspective, successful civil commitment reform would use commitment less, use it only when needed, steer individuals away from the most restrictive forms of commitment to less restrictive forms, and place greater reliance on the systems that require the least amount of government. We know how to do that.
Preventing the mass civil commitment and incarceration of people with mental illness requires lowering the commitment hurdle to something below imminently, provably dangerous.
Once we understand that treatment can prevent violence in those prone to it and that the "choice" to go off medications is not being made of free will but because the brain is impaired, the libertarian objective should be to restore free will, not stand back so violence can occur.
Some alternatives to inpatient commitment, in order from most restrictive to least restrictive, are guardianship, parole or conditional discharge from hospital after involuntary commitment, and Assisted Outpatient Treatment (AOT).
Current civil commitment practices fail to result in the libertarian objective of having fewer individuals incarcerated, public safety protected, and government growth restrained. Using lower commitment standards combined with less restrictive treatment venues can reduce the number incarcerated, shorten length of commitments, improve safety of the citizenry, and reduce the size of government. Reforming civil commitment practices can free people with serious mental illness "from the Bastille of their psychoses—and restore their dignity, their free will and the meaningful exercise of their liberties."
[1] Hardin, Herschel. “Uncivil Liberties” Vancouver Sun. July 22, 1993.
[2] http://mentalillnesspolicy.org/consequences/suicide.html
[3] http://mentalillnesspolicy.org/consequences/homeless-mentally-ill.html
[4] http://mentalillnesspolicy.org/consequences/1000-homicides.html
[5] Of spouses killed by a spouse, 12.3 percent of defendants had a history of untreated mental illness; of children killed by a parent, 15.8 percent of defendants had a history of untreated mental illness; of parents killed by children, 25.1 percent of defendants had a history of untreated mental illness; and of siblings killed by sibling, 17.3 percent of defendants had a history of untreated mental illness. 1994 Department of Justice Statistics Special Report, "Murder in Families.”
[6]http://mentalillnesspolicy.org/crimjust/120LEOSkilledbyMentallyIll.htm
[7] The Treatment Advocacy Center runs a fascinating online database called “Preventable Tragedies” that documents mentally ill who have been shot by police or become violent to others.
[8] See this research on officers shooting persons with mental illness.
[9] http://www.youtube.com/watch?v=Ku42PPzYEqs
[10] http://www.cnn.com/2012/08/16/us/michigan-police-shooting/index.html
[11] Here is a summary of studies of incarcerated mentally ill.
[12] Michael C. Biasotti, VP, New York State Chiefs of Police “Management of the Severely Mentally Ill and its Effects on Homeland Security” Naval Postgraduate School. 2011.
[13] Department of Justice Source Book on Criminal Justice Statistics (1996). $15 billion is based on an estimated cost of $50,000 per ill inmate per year, and 300,000 individuals with serious mental illness incarcerated.
[14] Van Horn, J.D., and McManus, I.C. (1992). "Ventricular Enlargement in Schizophrenia. A Meta-Analysis of Studies of the Ventricle:Brain Ratio (VBR)." British Journal of Psychiatry160, 687–97; Soares, J.C., and Mann, J.J. (1997). "The Anatomy of Mood Disorders: Review of Structural Neuroimaging Studies." Biological Psychiatry 41, 86–106; Elkis, H., Friedman, L., Wise, A. et. al. (1995) "Meta-Analyses of Studies of Ventricular Enlargement and Cortical Sulcal Prominence in Mood Disorders. Comparisons with Controls or Patients with Schizophrenia." Archives of General Psychiatry52, 735–46.
[15] Lawrie, S.M, and Abukmeil, S.S. (1998) "Brain Abnormality in Schizophrenia: A Systematic and Quantitative Review of Volumetric Magnetic Resonance Imaging Studies."British Journal of Psychiatry 172, 110–20.
[16] Schroder, J. et. al. (1992). "Neurological Soft Signs in Schizophrenia." Schizophrenia Research 6, 25–30.
[17] Torrey, E.F. et. al. (1994). Schizophrenia and Manic-Depressive Disorder. New York: Basic Books: 127, 176-7 (1994); Goldberg, T.E., and Gold, J.M. (1995) "Neurocognitive Functioning in Patients with Schizophrenia: an Overview." In: Bloom, F.E. and Kupfer, D.J. (eds). Psychopharmacology: The Fourth Generation of Progress. New York: Raven Press; Hoff, A.L., Shukla, S., Aronson, T. et. al. (1990). "Failure to Differentiate Bipolar Disorder from Schizophrenia on Measures of Neuropsychological Function." Schizophrenia Research 3, 253–60; Morice, R. (1990). "Cognitive Inflexibility and Pre-Frontal Dysfunction in Schizophrenia and Mania." British Journal of Psychiatry 157, 50–4; Berman, K.F., and Weinberger, D.F. (1991). "Functional Localization in the Brain in Schizophrenia." In: Tasman, A. and Goldfinger, S. (eds.).Review of Psychiatry vol. 10. Washington, D.C.: American Psychiatric Press, 24–59.
[18] Andreasen, N.C., et. al. (1992). "Hypofrontality in Neuroleptic-Naive Patients and in Patients with Chronic Schizophrenia." Archives of General Psychiatry 49, 943–58.
[19] Goldberg TE, Ragland JD, Torrey EF et al. "Neuropsychological Assessment of Monozygotic Twins Discordant for Schizophrenia." Archives of General Psychiatry47 (1990): 1066-1072; Goldberg TE, Gold JM. "Neurocognitive Functioning in Patients with Schizophrenia: an Overview." In FE Bloom and DJ Kupfer (eds.), Psychopharmacology: The Fourth Generation of Progress, New York: Raven Press, 1995, pp. 1245-1257; Gourovitch M, Goldberg TE. "Cognitive Deficits in Schizophrenia: Attention, Executive Function, Memory and Language Processing." In C. Pantelis, H. E. Nelson, and T. R. E. Barnes (eds.), Schizophrenia: A Neuropsychological Perspective, New York: John Wiley, 1996;
[20] “What are the symptoms of Schizophrenia,” National Institute of Mental Health.
[21] Torrey, Fuller, MD. “Bazelon Center is Wrong – Weston and Goldstein Refused Treatment and Services.”
[22] A collection of anosognosia research at MentalIllnessPolicy.org.
[23] A summary of some of the research on involuntary medication and Assisted Outpatient Treatment at MentalIllnessPolicy.org.
[24] Satel, S. and Jaffe, DJ, “Violent Fantasies” National Review July 20, 1998, pp. 36-37.
[25] National Institute of Mental Health.
[26] A two summaries of the research can be found at MentalIllnessPolicy.org.
[27] Interestingly, from a libertarian perspective, this means the mental health system is treating all others. It prioritizes the least ill and sends the most seriously ill to jails, prisons, shelters, and morgues. This has caused a giant and wasteful mental health industry that rather than serving a core state function of helping those who can’t help themselves, is instead, helping all others. See DJ Jaffe, “Mental Health Kills Mentally Ill,” Huffington Post, January 10, 2010.
[28] O’Connor v. Donaldson, 422 U.S. 563 (1975) and others.
[29] Admittedly, some may be what libertarians call ‘victimless’ crimes like possession of narcotics, prohibited pornography, soliciting a prostitute and others.
[30] John Stuart Mill. On Liberty, 1859.
[31] Testimony given at meeting of West Virginia Subcommittee C of the Joint Judiciary Committee August 13, 2012.
[32] There have been at least ten studies on delayed treatment leading to poorer prognosis.
[33] All treatments have side effects. All decisions involving treatment, voluntary or not, should balance these side-effects against the efficacy of the treatment.
[34] When Nevada County, CA recently introduced Assisted Outpatient Treatment, they found “County counsel cost is minimal…. Public Defender cost varies, but there would likely be few new or additional costs, because these same individuals would need representation in Criminal Court, Mental Health Court, or Adult Drug Court, if not being dealt with in (outpatient commitment) Court. (Michael Heggarty, Nevada County Behavioral Health, Carol Stanchfield, Turning Point Providence Center, Honorable Judge Thomas Anderson, Nevada County Superior Court. “Assisted Outpatient Treatment in California: Funding Strategies” February 7, 2012.
[35] 1995 Wisconsin Act 292 51.15 (1) (a) (5).
[36] See NYS Mental Hygiene Law § 9.60 (c); CA WIC, Article 9 5346(a) or Treatment Advocacy Center model law.
[37] Many people have questions about how monitoring is accomplished. We already monitor those in the parole system and those with TB living in the community. Likewise we have teams of social workers who monitor the non dangerous mentally ill. There are many feasible existing ways to accomplish monitoring. At minimum, a family member or significant other, or community member could report the reemergence of symptoms to a doctor, social worker, psychiatric nurse, law enforcement officer or other person who could determine if the person needs to be brought to a hospital for evaluation. Assertive Community Treatment (ACT) teams can also be used.
[38] A summary of studies on Kendra’s Law.
[39] Michael Heggarty, Behavioral Health Director, Nevada County. “The Nevada County Experience,” Nov. 15, 2011; County of Los Angeles. “Outpatient Treatment Program Outcomes Report" April 1, 2010 – December 31, 2010.
[40] Phelan JC, Sinkewicz M, Castille DM, Huz S, Muenzenmaier K, Link BG. "Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State." Psychiatric Services 61. No 5 February 2010.
[41] Bruce G. Link, Ph.D., et. al. "Arrest Outcomes Associated With Outpatient Commitment in New York State." Psychiatric Services. May 2011.
[42] Savings calculation at KendrasLaw.org.
Wednesday, August 22, 2012
A Libertarian Plan to Improve Involuntary Commitment Procedures
Current civil commitment policies protect neither the liberty of persons with mental illness nor the liberty of the public. They have increased government intrusion, increased public costs, and are inhumane. Changing to scientifically based commitment procedures can increase the liberties of individuals with mental illness, increase the liberties of those without mental illness, and help downsize government. Therefore, improving civil commitment laws should be a goal of libertarians.I argue that because schizophrenia is a real disorder that can impede rational thinking and free will, and that treatment can restore it, that mandating treatment would result in greater liberties for people with mental illness by cutting down on incarceration and inpatient commitment. It would also open the doors to shorter commitments and the used of less restrictive treatment venues. You can read the whole piece at http://www.cato-unbound.org/2012/08/22/the-editors/letters-a-libertarians-proposal-to-reform-involuntary-commitment/
Saturday, March 17, 2012
Recent Trends in Mental Illness
Trend: More psychiatric hospitals close. Local NAMIs start to fight back.
The trend towards closing state psychiatric hospitals in spite of a massive psychiatric hospital bed shortage is continuing in states like Massachusetts in Illinois, in Alabama, and Washington and elsewhere. NYS announced massive closures and the NY Daily News ran our op-ed in opposition. And when they tried to close a psychiatric unit at Cedar Sinai in Los Angeles, LA NAMI protested. NAMI E. Flatbush NY protested the closing of Kingsboro Psychiatric Hospital in Brooklyn. Historically, NAMIs have accepted hospital closures in return for the promise of community services that never materialize. Nice to see them not falling for it again. It would be great to see state level organizations join in.
Trend: Criminal Justice Systems are taking lead in advocating for better care for seriously mentally ill because Mental Health Departments are failing so miserably.
As a result of mental health departments taking a laissez faire attitude towards serious mental illness, there are more people incarcerated for mental illness than hospitalized. For example, the shooter of seven at Western Psychiatric Hospital turns out to have been mentally ill, known to mental health system, and left untreated. Incidents like this are causing some law enforcement officials to make getting better treatment for people with mental illness a priority, so they don't have to step in.
- American Police Beat Magazine ran a story we wrote, "Police overwhelmed by Mentally Ill", based on a survey by Police Chief Michael Biasotti.
- An Ohio Sheriff announced he is refusing to allow police to drop people with mental illness who are violent off at his jail. He wants them to get treatment instead. This was fantastic news and the first time we've ever heard something like that. MIPO supported the Sheriff .
- A sheriff in Cook County, IL has threatened to sue the mental health department to stop them from refusing to treat people with serious mental illness.
- The Department of Justice issued Community Policing Guidelines which endorsed AOT as a way to return treatment to mental health departments. Another announcement from DOJ is imminent.
Trend: Consumers buck consumertocracy
More and more consumers are exercising their independence and speaking out. Natasha Tracy, a great consumer blogger wrote, "Human Rights and AOT" and about non-compliance.
My favorite quote this month, was from Consumer Blogger Andrew Behrman in "Dump Stigma and Focus on Recovery" who wrote, "The stigma started with me. I initiated it. It was my own fault & result of my naivete"
The Substance Abuse and Mental Health Services Agency (SAMHSA) conducted a survey asking their largely consumer constituency what the top advances in care were over the last twenty years. Assisted Outpatient Treatment made top five. Unfortunately, SAMHSA has a habit of ignoring issues that only affect people with serious mental illness. As we wrote on Huffington Post, SAMHSA's widely quoted report on Mental Illness in America ignored 500,000 seriously mentally Ill
On the other side some government funded professional consumers ("consumertocracy") are still promoting nonsense.
- One professional consumer wrote that because there is no biological test for schizophrenia, it must not exist. That's kind of like arguing that colon cancer didn't exist before the colonscope was invented. (BTW, there is no biological test for Parkinsons either. Yet it exists.)
- Many professional consumers are using the fact that people with mental illness die earlier than others as an argument against medications. But many of these premature deaths are due to side effects of non-treatment. For example suicide, homelessness, incarceration, and lack of medical care.
- Robert Whitaker's Anatomy of an Epidemic repeated many of these arguments without any information on the other side.
In Brief
- Major study says 'art therapy' does not work for people with schizophrenia
- Scientist asks for proof that anti-stigma campaigns work
- APA Task Force Report on Outpatient Services for the Mentally Ill Involved in the Criminal Justice System argues for preserving psychiatric hospitals and using mandated outpatient treatment
- Short Sweet Video of Dr. E. Fuller Torrey on his updated book: The Insanity Offense, which includes the most comprehensive information on Jared Loughner who suffered from untreated mental illness and shot Gabrielle Giffords. (Must-reading)
- "Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill" by Mary Beth Pfeiffer is really wonderful. She shows how tiny episodes of mental illness feuled behavior can snowball and result in permanent incarceration. Two thumbs-up. (Don't confuse this with another excellent book: Pete Earley's, "Crazy: A Father's Search Through America's Mental Health Madness")
- Treatment Advocacy Center Preventable Tragedies database lets you search incidents of violence by and to people with mental illness in your own state. Powerful tool to advocate for changing laws
Around the states
California
Laura's Law and ever increasing incidents of violence by mentally ill individuals took center stage in California. A bill to Extend Laura's Law was introduced and given huge support by San Francisco Chronicle. A brilliant Sacramento Bee op-ed by psychiatrist Gary Tsai says cuts to mental health programs shift burden to law enforcement. To help people keep up, we launched a special site on Laura's Law and the Mental Health Services Act with lots of useful information. Unfortunately mental health directors, Disability Rights California, and consumer groups have formed a coalition designed to prevent people with mental illness from receiving treatment until after they become dangerous. While done in the name of 'civil rights', this results in people becoming incarcerated and losing all rights.
The other big California story is Proposition 63/Mental Health Services Act money being diverted away from serious mental illness. For instance, it is funding the opponents of Laura's Law. Mary Ann Bernard, Of counsel for Mental Illness Policy Org wrote a great piece in California Progress Report on this, and DJ Jaffe, ED of MIPO wrote a a separate story, "Proposition 63 fails to serve seriously mentally ill" in Capital Weekly.
New York
MIPO testifies that NYS Commission on Quality of Care fails mentally ill and we wrote an op-ed in New York Daily News criticizing proposed closings of psychiatric hospitals.
VA
Pete Earley on failure of Virginia mental health system
TX
Judge rules mentally ill incompetent to stand trial are being held in jail for too long before being moved to hospital
VT
Report calls for better care to prevent incarceration of mentally ill
MA
MA agrees to treat mentally ill prisoners better and revised their Civil Commitment practices.
Thank you for your support of Mental Illness Policy Org. This is a labor of love, and if you can afford it, we can use your tax-deductible donations.